GAMC health plan hits new snag

  • Article by: WARREN WOLFE , Star Tribune
  • Updated: August 23, 2010 - 11:09 PM

Payment formula for four hospitals treating the state's neediest gives edge to HCMC.

State officials said Monday they might retool the payment formula for hospitals participating in an experimental new health plan for some of the state's poorest residents -- a further sign that the revised General Assistance Medical Care (GAMC) program launched last spring is not working out the way authorities had hoped.

The discussions began because Hennepin County Medical Center (HCMC) in Minneapolis has had a smaller percentage of potential patients enroll than the other three participating hospitals and, as a result, is getting paid more than twice the amount per patient.

The state "is evaluating the enrollment patterns and [payment] options," said Bonnie Martin, a spokeswoman for the state Department of Human Services. So far, about 12,350 patients have signed up to receive coordinated care at the four hospitals, but enrollments have not been evenly distributed.

The department also acknowledged Monday that a second hospital -- University of Minnesota Medical Center, Fairview -- has surpassed its patient enrollment limit, and that no new GAMC patients will be added to that hospital's "coordinated care delivery system" after next Friday.

North Memorial Medical Center in Robbinsdale hit its limit three weeks ago.

That leaves Hennepin County and Regions Hospital in St. Paul for about 20,000 GAMC patients statewide who have not yet selected one of the four hospitals for coordinated care -- and Regions said Monday it expects to hit its enrollment cap in one or two weeks.

Last week, 408 new patients signed up for coordinated care. Even if Hennepin County reaches its full enrollment, the program would cover 17,236 patients, leaving about 12,000 without coordinated care. Those left out must find clinics offering charity care, get care from hospital emergency rooms or go without.

Problems from the start

The developments are another sign that the revised GAMC program is not working out as Gov. Tim Pawlenty and lawmakers hoped. Under a compromise negotiated in the final hours of the legislative session in May, officials expected 17 hospitals around the state to offer GAMC patients medical care through "coordinated care delivery systems." They were to provide clinical, hospital, chemical dependency and psychological care as well as some social services to all GAMC patients who sought it.

In exchange, the hospitals would be paid lump sums -- about one-fourth of the amount paid last year -- based on historic use by GAMC patients.

But the hospitals refused to join until three weeks before the revised program took effect -- and four joined only after the state changed the rules and agreed to enrollment limits at each hospital, protecting them from unrestricted risk.

The experimental system is unlike any other in the nation. In theory, low lump-sum payments encourage hospitals to keep patients healthy so they avoid costly emergency-room and in-patient care.

But from the beginning, some patients have had difficulty getting access to appropriate care. The latest flaw -- the huge difference in what hospitals are paid per patient -- is a product of the enrollment limits.

As of last Friday, HCMC had 4,219 GAMC patients, well below its cap of 9,656 patients, and Regions had 3,250, just short of its 3,465 limit. University Fairview had 2,534 patients, over its cap of 2,441; North Memorial had 2,233, above its 1,977 patient limit. The result is that HCMC is getting far more per patient than the other hospitals.

"We knew there was some risk when we got into this," said Ryan Davenport, spokesman for University Fairview. "We knew the system wasn't necessarily fair. We just don't know if anything can be done about it."

Warren Wolfe • 612-673-7253

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